Provider Demographics
NPI:1144464876
Name:GOLF MILL PHARMACY AND MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:GOLF MILL PHARMACY AND MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DEYSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:847-803-3340
Mailing Address - Street 1:8334 KARLOV AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2738
Mailing Address - Country:US
Mailing Address - Phone:847-803-3340
Mailing Address - Fax:
Practice Address - Street 1:8941 W GOLF RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5812
Practice Address - Country:US
Practice Address - Phone:847-803-3340
Practice Address - Fax:847-803-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL0540166313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119936OtherPK
2119936OtherPK
IL=========001Medicaid